Anesthesiologists may be asked to work in atypical situations in which features of the environment or procedure require additional resources or increased cognitive load that threaten patient or staff safety.

Nonoperating room anesthesia (NORA) is a rapidly growing anesthesia service that includes the MRI environment. NORA presents many challenges for patient safety due to increased patient and procedure complexity coupled with lack of access to familiar team members and equipment and technology that are typically found in ORs. NORA cases have higher safety risks and more risk of severe injury and mortality compared with OR cases. Follow the ASA guidance for NORA safety and align patients and families’ perception with the risks of these procedures during the consent process.

“By taking a proactive approach to medication and supply shortages, clinicians can ensure that they continue to provide the right care to the right patient at the right time regardless of limitations imposed by the supply chain.”

Magnetic fields in the MRI suite can turn equipment into projectiles, and radiofrequency energy can affect implanted devices, changing the programming in pacemakers or pumps or causing patient injury. The time-varying field can induce electric currents in conductors, resulting in monitor artifacts and patient burns. Hidden ferromagnetic objects, like clips or bullets, may move during the scan, causing injury. A strong partnership is needed with MRI technologists to screen patients and staff before entering scanning rooms. Staff education is essential, MRI-compatible equipment is needed, and patient resuscitations must never occur in the scanning room. At all phases of care, clear and timely communication is essential.

Unfortunately, medication and medical supply shortages are now common and pose a threat to safe patient care. Practices should be proactive and develop a plan for dealing with shortages before they occur, including establishing communication with supply chain personnel, considering an emergency stockpile, and staying informed of impending shortages. Hospitals need processes for managing scarce resources and tracking and reporting any complications that result from substitute medications/supplies. It is important that clinicians receive education whenever substitute or unfamiliar medications/supplies are introduced into clinical practice to reduce the possibility of errors. By taking a proactive approach to medication and supply shortages, clinicians can ensure that they continue to provide the right care to the right patient at the right time regardless of limitations imposed by the supply chain.


Crew/crisis resource management (CRM) is a foundational aspect of patient safety and encompasses several principles and related domains. Foundational hallmarks of CRM from NASA include interpersonal communication, leadership, and decision-making. In Miller’s Anesthesia, the listed five main elements of CRM are communication, task management, situation awareness, teamwork, and decision-making. Guidelines that embrace principles of CRM and human factors include considerations for team dynamics, post-event debriefing, calling for help, closed-loop communication, teamwork, organization, and the design of safe working environments. Overall, CRM is an essential aspect of patient safety when its principles are incorporated in the implementation of perioperative quality/safety initiatives.

Mass casualty incidents (MCIs) are events that result in an overwhelming surge of patients. Crisis standards of care (CSC) may be invoked to best utilize limited resources to save the most lives. Surgeries should be lifesaving rather than definitive. Standard safety principles pertain to MCIs, including CRM, system preparation, and care for team members. Most hospitals are not prepared. No-notice exercises illuminate areas for preparation before an MCI. Hospital incident command provides coordination that is flexible, scalable, and adaptable to any hazard. Priorities are life safety, incident stabilization, and property preservation, with deliberate distribution of Space, Staff, and Supplies. MCIs are stressful to systems and individuals, and health care providers may become second victims. Recovery may be prolonged.

Anesthesiologists experience occupational safety hazards that include burnout, stress, substance use disorder (SUD), and second victim syndrome. Suicide risk is high among anesthesiologists (1.9 times higher than surgeons and 6.5 times higher than pediatricians). Minimizing drug diversion needs to focus on prevention, standardizing drug testing, reporting processes, treatment options, compliance, accountability, and reducing associated stigma. Primary prevention includes improving well-being by promoting autonomy and flexibility, self-awareness, and self-care. Caring for colleagues with distress, depression, SUD, and suicidal risks is critical, as are peer-support programs for second victims. Robust resources for anesthesiologists’ well-being exist via ASA and the American Medical Association, along with national suicide prevention hotlines.

Psychological safety describes the felt permission for candor that enables teamwork to thrive and for others to speak up – to disagree with the leader, ask for help, and admit errors without the fear of being humiliated, blamed, or ignored. Psychological safety exists at the group level; the local authority figure has the most powerful influence on the climate of the team environment. In the OR, anesthesiologists are in a crucial position to create psychological safety. They can ask open-ended questions to encourage contribution, such as, “What do I have wrong about this?” Always appreciate the thoughts and suggestions offered and be willing to discuss. Such actions highlight to the team that they have been heard, not ignored, and serve as learning moments.